Excerpted from Physical: An American Checkup, by James McManus, to be published by Farrar, Straus and Giroux, January 2006. © 2006 by James McManus
Photograph: Jennifer Arra
Grace McManus, shown here in her metal eye shield, was given so many different drugs for her eye that her mother devised a sticker chart to keep it all straight.
Just before three in the afternoon on Friday the 13th of February, 2004, my wife, Jennifer, called to tell me that the right eye of Grace, our four-year-old daughter, had been punctured by a two-pronged wire sticking out from the end of a magic wand at a children's birthday party. From my scalp to my bowels, I shuddered. At least one of my feet left the carpet, as though a prankster had tapped below my kneecap with a pink rubber mallet.
Calling from our car, Jennifer wavered between panic and her usual impatient efficiency. Gracie's eye. Serious. Meet us at Lewy's office. Think she'll be OK, but . . . .
The office of Peter Lewy, our daughters' pediatrician, was only six blocks from the party, and Jennifer decided she could get Grace into a doctor's care sooner at Lewy's than if we risked whatever lines and red tape might be waiting at Evanston Hospital, three miles south of our house.
"But won't the ER be able to handle-?"
"Just be ready!" she said, and hung up.
When the car arrived in our driveway a few minutes later, I climbed into the back and held Grace, who stayed buckled into her car seat. She's a very tough cookie, as the youngest in the family often is, but now she was whimpering in pain, scrunched up as fetal as the seat belt would allow.
"Please let me look, Gracie girl. Daddy has to."
When she finally let me for a couple of seconds, I tried to force myself not to cringe.
Didn't work. From what I could tell, Grace's right eye was shaped like an underinflated basketball someone had stepped on. Blood and some blue from her iris were leaking from two lacerations near the center of her cornea. It looked almost as dark as a shark's eye. Hugging her, trembling, I turned to her mother. "How did this happen, for Christ's sake?"
"They were playing with magic wands," Jennifer told me. "One of the tips fell off. These wires were sticking out."
At Dr. Lewy's office, we were immediately taken into a darkened examining room. Jennifer laid Grace face-up on the table and began massaging her torso and arms, trying to keep her from touching the eye. I did the same from above Grace's head, where I stayed when Dr. Lewy walked in. Grace was shivering, pawing her face, positively shrieking when we tried to tug her hand away so Lewy could examine her. His expressions and body language made it clear that though he wasn't having much luck seeing what was wrong, the injury wasn't minor. Unable to get drops into the eye, he fixed a soft cloth patch over it and had a nurse get on the phone to make arrangements for Grace to be seen by Deborah Fishman, a pediatric ophthalmologist in Wilmette, maybe three miles away. When? "Right now," Lewy said, flooding us with relief and more terror.
We didn't talk much in the car. If an appointment with a specialist had been secured this expeditiously late on a Friday afternoon, the condition of Grace's eye must be dire. We did our best to make her less scared. Just one more doctor, OK? This one will make it all better. . . .
By the time Dr. Fishman determined that Grace's injury "went too deep" for her to treat, we knew we were in a bad place. "The double laceration, combined with the depth of the punctures . . . ." Stop it! Please stop! Though we both did our best not to let Grace know how terrified we were, Fishman's "too deep" remark multiplied our panic by an order of magnitude. Even Jennifer had started to lose it, and I knew that spelled doom, since she was the cool, rational half of the tag team. In the meantime, using her good eye, Grace had spotted a tin of what she called "lowly-pops" and asked Dr. Fishman if she please could have one.
"Oh, better not, sweetie," Fishman told her gently. Turning to Jennifer, she whispered, "If she needs to have surgery, she should have an empty stomach."
Fishman told us she would try to get Grace in to see Peter Rabiah, a surgeon who could treat this injury, though Fishman wasn't sure it would be possible to reach him this late in the day. She called Children's Memorial Hospital, cut through the paging madness to find out where Rabiah was, actually got the guy on the phone, and arranged for him to look at Grace's eye. God knows how, but she did it.
Two hours and 40 minutes after the accident, we managed, with Deborah Fishman's and, less directly, Peter Lewy's help, to deliver Grace into the hands of Peter Rabiah, a pediatric ophthalmologist affiliated with Children's and Evanston Northwestern Healthcare. Another huge factor was our Cigna insurance card, plastically representing a policy issued for free by my employer, the Art Institute of Chicago, whose plan is handled by Fred Novy. For a bimonthly payroll deduction of $115.60, my family is covered as well. Once Grace's primary care physician (Lewy) set the ball rolling, whoever saw Grace after that, and whatever procedure he or she performed, would be covered.
It turned out that Dr. Rabiah was only up our way because of a weekly staff meeting at Glenbrook Hospital. Normally he was off duty by five, but the meeting ran long for some reason. His colleagues and nurses and office staff had all gone home as he waited for us in his suite of dark offices. Medium height and build, pale olive skin, balding, dark hair, visibly tired at the end of a long day and week-the most beautiful person we'd ever laid eyes on. We introduced ourselves and thanked him profusely for being there.
"Let me have a look."
But Grace wouldn't let him, at least not in the ways and from all the angles he wanted to. She was simply too scared, in too much pain, to sit still for her third doctor, especially after we had promised during the previous consultations that each was the last one she would have to submit to. She was also getting hungry and thirsty. Even with both parents reassuring her while trying to hold her in place, Rabiah was unable to examine her thoroughly. There were drops he wanted to put in, a device he wanted to use. Nothing doing. By simply covering Grace's left eye with his hand, however, he was able to determine that she had zero vision in the right. After looking a little while longer, cocking his head this way and that, he told us, "She has two full-thickness corneal lacerations, one at about the 12-o'clock position and one at about two o'clock. The lacerations are midperipheral, and her-"
"Not directly over the visual axis, though it's close."
Bewildered and crazed, I just nodded.
"The anterior chamber is shallow," he said, "though formed. Some iris strands have prolapsed into the two lacerations, where they've become incarcerated." His soft-spoken voice made all this easier to understand but also more devastating. I could tell it was killing my wife. But we listened; he talked. He needed to put Grace under general anesthesia to thoroughly examine the eye and try to repair it.
Now we gaped at him, begging for promises, answers, predictions. This was a seasoned pediatric ophthalmologist, an exquisitely talented surgeon, and Grace's only hope. He was not optimistic. "This is a serious open-globe injury," he told us in a not-quite-neutral tone of voice. "The visual prognosis is guarded." As Jennifer put Grace's coat on her in the waiting area, he also had no choice but to hold my gaze for a few extra beats: "You need to be aware that children this age can die under general anesthesia."
We sat with Grace on a couch as Rabiah called Evanston Hospital and reserved an operating room. "Evanston Hospital has a more sophisticated trauma center," he said.
Rabiah in his car and we in ours, we drove the ten miles to Evanston. I didn't tell Jennifer what Rabiah had said about anesthesia. She understood that already, didn't need to hear those foul words. We were altogether helpless in this good doctor's hands, but we knew we were lucky to be there. If Fishman had reached him ten minutes later, he would have been out the door, headed home or to a restaurant, starting his weekend with a vodka martini perhaps, effectively shunting Grace's blind eye under the knife of a junior associate.
Grace didn't believe us, of course, when we promised her that the next stop would be the last of the night. I wasn't that certain myself.
At Evanston, Jennifer did most of the signing and talking. She knew the story of the injury firsthand, as well as the embarrassing fact that Grace's dad couldn't bear to think about the hideous details, let alone repeat them for every new "intake specialist" who strolled into the room. I was frantic to get the surgery under way but impotent to make anything happen. Not dropping Grace was the extent of my usefulness.
We were soon introduced to a confident, muscular young guy with a gleaming brown skull, big white teeth, and ripped 'ceps emerging from his short-sleeved hospital top. He wore a chain around his neck-no delicate links to display a modest crucifix or St. Christopher medal, but a chunky inch-wide affair fitted tightly below his Adam's apple. Was this hard, kinky brother the orderly charged with wheeling our vulnerable daughter into the operating room? No, he was Dr. Rouse, who'd be assisting Dr. Rabiah in the surgery. The anesthesiologist was an Egyptian-looking guy who resembled Omar Sharif, only stockier. He pressed us to be precise about when Grace had eaten last. (2:30 p.m.) What? (Birthday cake.) How much? (Just one piece.) At last an orderly with no chains of any sort around her neck arrived to wheel Grace through the door, beyond which Peter Rabiah was waiting.
How annihilatingly ridiculous it was for me to pray that the surgery would be successful, though I caught myself doing it, after a fashion at least. That very afternoon I had written in an article for Esquire magazine: "Religion evolved to help us cope with poverty, imprisonment, fear of death, and other bad things, and that's fine. But is some white-bearded guy named Jehovah or Olodumare, God or Allah really out there? In here? On a throne up in heaven, above and to the left of Cloud 9?" But that's pretty much where I was aiming my supplications. Nor could I help picturing Grace on the table, face-up under a microscope, eye pulled wide open and cut, surrounded by three dark strange men and all those damn lights and equipment. Two hours later, Rabiah comes out to report the initial results. Neither optimism nor pessimism colors his voice. "She has a long haul ahead of her, but her retina was untouched, and her lens, while traumatized, was intact." He'd been able to inject a gel into her eye, he says, to rebuild the cornea and help it begin to repressurize.
He lets one of us-Jennifer-go back to be there when Gracie comes to. My gratitude and relief upon hearing his guardedly hopeful prognosis are so overwhelming that I don't know what to say. "It didn't look like much of an eye this afternoon."
"Was it worse because there were two?"
"The double punctures didn't change much in terms of her vision, because it depended where they were exactly, and neither was in the worst spot."
Two punctures doubled the opportunities for infection, however. We would have to be extra vigilant with antibacterial drops. I promised him we would be and thanked him and thanked him and thanked him. How did he learn to do this miraculous thing? By having brains and steady hands but also by working his ass off.
Googling Peter K. Rabiah, we find that he graduated from the University of Michigan Medical School in 1988, following that with a residency in ophthalmology at the University of Illinois at Chicago. A yearlong fellowship in uveitis (inflammation of the pigmented layer of the eye) at Illinois and another in pediatric ophthalmology at UCLA. Board certified in ophthalmology, 1994. Graduating from college around 1984 made him a little over 40, I figured; his name and features made him appear Arab American.
He wouldn't have been hired to work and teach at Northwestern, one of the best medical programs anywhere, if he weren't really good at his job going in. After that, during ten years of practice, it's fair to assume he got better and better: sharper diagnostic skills, more precision under the microscope, more effective follow-up protocols. An accomplished healer to begin with, he got used to dealing with some of the toughest cases in Chicago, as well as some of the traumas and complications that ophthalmologists throughout the Midwest couldn't handle.
Here's the kicker. Google also takes us to the Web site of the International Centre for Eye Health, where we learn that a year before Grace's accident, someone had published a paper called "Penetrating Needle Injury of the Eye Causing Cataract in Children" in the distinguished journal Ophthalmology. The author was Peter K. Rabiah.
The guy we had lucked into was the very surgeon you would want peering through the microscope and supervising the aftercare if your child's eye got injured this way. If his study had been written less recently, the state of the art might have changed. As it was, Peter Rabiah was almost ridiculously well prepared to save Grace's eye. The care she received was as good as it gets, probably could not be improved on. If only we had known this as we drove her to the hospital that night, or argued about where to go first! Thank God Dr. Rabiah was available, we kept saying to ourselves and telling each other. God forbid that a second-rate surgeon would have handled the case.
What's the difference between God and a surgeon? God doesn't think he's a surgeon.
A plumber attended to a leaking faucet at a surgeon's house. After a two-minute job, he demanded $150. The surgeon exclaimed, "I don't even charge that much and I'm a surgeon!"
The plumber replied, "I didn't either when I was a surgeon. That's why I switched to plumbing."
Then there's the young girl who tells her parents, "A boy in my class asked me to play doctor."
"Oh, dear," say her parents, wringing their hands. "What happened, honey?"
"He made me wait 45 minutes, then double-billed the insurance company."
The blood sport of doctor bashing is all well and good and quite often terribly funny. No doubt many doctors deserve heaps of enmity and/or prison time, if not Texas justice itself. Even so, a whole lot of folks underestimate how arduous and expensive it is to obtain a diploma that simply gets your foot in the door of a serious teaching hospital. A full-scale scientific or medical education, from college through postgraduate work, costs more than a million dollars. Certainly the prospect of a handsome income is a motivating factor, but so is pure altruistic heart. How else could these folks make it through the long educational process? Premed types and science wonks have to skip a lot of tailgate parties, hot dates, and greet-the-dawn poker sessions to get the kind of grades that make them eligible for med school.
Once they get admitted to med school, they can kiss their social life and nightlife goodbye. Yet delaying gratification and working their ass off in med school barely prepares them for the staggering grind that interns put up with: 50-hour days in a series of life-and-death situations for salaries on a par with those of nannies and construction workers, not a twelfth of what banjo-hitting utility infielders make. What nannies and laborers do is plenty important, but we owe smart M.D.'s our lives.
When Peter Rabiah was in his mid-30s, he was still going to school to learn how to keep children from going blind. In fact, because of the way the literature of his specialty happily keeps expanding (in part because of him), he will be in school until he retires. Did I mention that he keeps injured and sick children from going blind, but that the way he carries himself in his practice couldn't be more unassuming? If a child needs his expertise late of a Friday, when he's already halfway out the door, he stays on for several more hours. (This happens irrespective of insurance coverage, by the way, because the hospital group pays him a salary that doesn't depend on how much they collect from individual patients. Plus it's virtually unimaginable that any doctor would send an injured but uninsured child on her way. Her family might get dunned till the cows come home, but her eye will get treated just the same.) How much does Rabiah earn? Middle six figures, I'd guess. I'd also guess that without the possibility of being well compensated, his and a lot of other excellent doctoring, not to mention breakthroughs in the laboratory, simply wouldn't happen. Whatever income and status these people derive by keeping us out of the clinic or crematorium, they richly deserve.
Grace spent three days in Evanston Hospital receiving antibiotics intravenously. Jennifer stayed in the room around the clock and slept in Grace's bed with her. During the day she took a crash course in eyedrop technique and suture care, both critical to the healing process. She must have been a pretty good student because Grace was sent home sooner than expected. Along with her perforated metal eye shield and cool plastic ID bracelet, she's packing prescriptions for Vigamox (an antibacterial liquid to ward off endophthalmitis and other infections), atropine (synthetic belladonna to paralyze the sphincter muscle of the iris, maintaining dilation; also to reduce pain and prevent complications), and Pred Forte (a steroid to maintain healthy pressure and reduce inflammation).
Drugs this potent, especially in combination, especially in a child's eye, need precise management. We need to get each one into the eye three or four times a day, but not at the same time. As the dosages change, the protocol gets so complicated that Jennifer devises a sticker chart to keep it all straight, peeling off Hello Kitty stickers as rewards for holding still. The first few bandage brands we use to hold the shield in place irritate Grace's delicate skin; after two return trips to the drugstore, the Johnson & Johnson First Aid Hurt-Free Tape finally works. We also stock a "treasure chest" with Hello Kitty toys, Play-Doh, and jungle-cat coloring books, from which Grace can choose one item at the end of each week in which she "helps Mommy help me get better."
In the meantime, she can't go to school. No jumping, running, skipping, somersaulting, ice-skating, bike riding. Can't even go to the park because dirt or sand might get tossed or blown into her eye. Washing her hair takes an hour. No play dates for the first month or so, not even between drop applications; the responsibility would simply be too much to lay on another parent. In early March, Daddy begins a two-week tour to promote the paperback edition of Positively Fifth Street, his book about poker. On April 7th, with Daddy in Las Vegas, the rest of the family move into our new house.
Forty-six days after the accident-"Seems like 47," says Mommy-Grace once again goes under general anesthesia so Rabiah can remove the stitches. This time it's outpatient surgery, though still a big deal. It goes well. Easy as pie, as a matter of fact, especially for Daddy, since he's off in L.A. signing books.
At the post-op appointment three days later, Daddy is around. When the smiling Nurse Rebecca tries to put in drops that would illuminate any scarring in the eye, Grace politely informs her, while wrenching herself from her grip, "I don't want the yellow drops! Nooooooooooooo!" Rebecca puts in a Dumbo video and calls the drops "raindrops." It works.
Once the drops have had time to work, in comes Rabiah. We all say hello as he opens a drawerful of lenses. Off go the overhead lights. His coal-miner ophthalmoscope makes Gracie laugh when he flicks on its beam. It's the moment of truth. He wheels his chair up good and close, takes hold of her face, peers into her eye, looks around. We watch him, watch Gracie.
"Looks good and healthy in here."
We exhale. On the monitor next to Dumbo, an eye chart for kids who can't read yet appears. Rabiah covers Grace's left eye, asking her to tell him what she sees.
"Your hand," Gracie says.
Now he laughs. "Over here, on the screen."
"A house . . . a boat . . . a car . . . a phone."
To test depth of field, he slides some high-tech lenses in oversize black frames onto her face. "Can you grab the fly's wings?"
She reaches out, tries to.
"Which animals are popping up at you?"
She gets those right as well.
"Which of the circles?"
After a few minutes more of the same, he tells us, "Excellent."
Turning back to Grace: "OK, you're all done." He gives her a pat as she hops into Jennifer's lap.
"Everything looks good. There are two scars in her cornea, but they won't affect her vision because they aren't centered over the lens. She was lucky. The ocular pressure in both eyes is normal. Both eyeballs are round, firm, and normal." She has 20/20 vision in the right eye, he tells us, 20/15 in the left "because of all the extra work it's been doing." Grinning like a couple of morons, we hold Grace and blubber our thanks.
Bottom line? Grace's eye has never worked or looked better, and Jennifer is feeling pretty proud of herself for getting us through the ordeal. Grace returned to school, to the park, to ballet class; she hosts and goes on play dates, and is just about ready to lose her training wheels.
And Peter K. Rabiah? He is officially and forever The Man. Grace's clear, huge, long-lashed, and flashing blue eye had been damaged, perhaps beyond repair; he repaired it. The more enthusiastically we communicate this to him during follow-up visits, the more embarrassed he becomes-which just makes him more of The Man.
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